Highlights from the World Health Organization 2nd International Consultation on Incontinence, July 1-4, 2001, Paris, France

Increasing Awareness and Improving the Care of Urinary Incontinence

MEETING REVIEW Increasing Awareness and Improving the Care of Urinary Incontinence Highlights from the World Health Organization 2nd International Consultation on Incontinence July 1–4, 2001, Paris, France [Rev Urol. 2003;5(1):22–25] © 2003 MedReviews, LLC Key words: Urinary incontinence • Overactive bladder • Bladder health questionnaire • Cost-of-illness • Quality of life n July of 2001, some of the world’s leading urologists and urogynecologists gathered in Paris for the Second International Consultation on Incontinence. The World Health Organization (WHO) organized this meeting. In the summer of 1998, the group first met in Monaco to increase awareness and improve the care of urinary incontinence worldwide.1 At that meeting, committees were formed to assess relevant information on various aspects of urinary incontinence, including epidemiology and voiding dysfunction in the elderly, and to develop guidelines based on these assessments. Also, the first consultation pledged to define strategies in both education and research.2 The I Reviewed by Christopher J. Chermansky, MD, and Michael B. Chancellor, MD, University of Pittsburgh School of Medicine, Pittsburgh, PA 22 VOL. 5 NO. 1 2003 REVIEWS IN UROLOGY principal task of the second consultation was to build on the work of the first consultation and further develop management plans for incontinence. What follows is a discussion of some of the outstanding presentations highlighted at the WHO meeting. Bladder Health Questionnaire To help health care professionals screen for patients with potential bladder health problems, the National Overactive Bladder Evaluation (NOBLE) research team developed and clinically validated the Bladder Health Questionnaire (BHQ). On behalf of this team, Payne and associates presented the results of this easy-to-use patient questionnaire.3 A sample of 1552 adults living in the Baltimore, Maryland, area completed a telephone interview about bladder health and bladder control problems. Of those interviewed, 254 participants were selected for a clinical evaluation. Before the clinic visit, participants completed a mailed, 32-item, selfadministered, draft questionnaire that queried how often bladder problems had occurred in the previous 4 weeks. Before the visit, participants also maintained a 1-week diary to record daily bladder symptoms and activities. At the clinic visit, each participant completed a midstream urinalysis. Before and during the examination, participants again completed the draft questionnaire; clinicians were blinded to the patient’s responses. During the examination, physicians rated each participant’s need for medical care on a scale of 0 (no need) to 10 (urgent need). In addition, physicians determined each participant’s benefit from treatment for bladder health problems on a scale from 0 (not at all) to 10 (a great WHO 2nd International Consultation on Incontinence Table 1 Estimated Number (in Millions) of Adults in the United States with Overactive Bladder OAB Type Women Men OAB Dry 7.9 13.2 21.1 OAB Wet 9.6 2.6 12.2 17.5 15.8 33.3 Total deal). A composite score (CARENEED) was derived from the medical need and potential benefit of treatment for bladder control problems, with a possible combined score ranging from 0 to 20. Finally, during the clinic visit, individuals completed selfadministered questionnaires to assess health-related quality of life (SF-36), depression status (CES-D), and quality of sleep (MOS-Sleep). Of the 32 items on the questionnaire, 5 were determined to be the Total bladder-health problems, thereby facilitating treatment for more incontinent patients. Prevalence and Economic Costs of Overactive Bladder Because the definition of overactive bladder (OAB) is not standardized, estimates of its prevalence vary.4 The NOBLE Program was formed to provide a valid research definition of OAB, estimate its prevalence among adults in the United States, and identify its Five questions were determined to be the best predictors of need for care. These included questions about nocturia, urge, bother/concern, incontinence, and pad usage. best predictors of need for care. These included questions about nocturia, urge, bother/concern, incontinence, and pad usage. In addition, 2 additional questions concerning pain on urination and the presence of blood in urine were included, because a “yes" to either of these questions indicates the potential presence of infection, interstitial cystitis, or cancer. The final BHQ is composed of these 7 questions. The authors concluded that the BHQ is highly reliable and internally consistent. Also, the correlation between the BHQ score and the physician’s evaluation of CARENEED was 0.78, which is strong. This study suggests that primary care providers may employ the BHQ to screen for impact on quality of life. On behalf of the NOBLE Program Research Team, Stewart and associates5 estimated the U.S. prevalence of OAB using a validated computer-assisted telephone interview. The overall prevalence of OAB amongst 5204 adults (age ≥ 18 years) sampled was unexpectedly similar between men and women (16.0% and 16.9%, respectively). Yet differences were noted between men and women who had OAB with and without incontinence (OAB Wet and OAB Dry, respectively). OAB Dry was defined as having at least 4 episodes of urgency over the past 4 weeks plus more than 8 voids per day or 1 or more bladder-control coping behaviors, such as decreased fluid intake or restricting travel to places with known bathroom availability. OAB Wet was defined as OAB Dry plus at least 3 episode of urge incontinence, excluding stress incontinence, over the past 4 weeks. Table 1 summarizes the differences. OAB Wet was more prevalent in women, whereas OAB Dry was more prevalent in men. Interestingly, the prevalence of OAB Dry increased markedly in both men and women over 44 years of age. In contrast, OAB Wet increased markedly in men over 64 years of age and in women over 44 years of age. In conclusion, approximately 33.3 million men and women, 16% of the U.S. population, suffer from OAB. In another study using the NOBLE Program results, Hu and associates6 studied the economic burden of OAB in the United States. To determine the cost-of-illness of OAB, direct and indirect costs at the community level and institutional costs were determined for the year 2000. Direct costs were composed of treatment costs (pharmacological, surgical, and home care), consequence costs (additional physician visits, additional nursing home admissions, urinary tract infections, skin conditions, fractures, and falls), routine care costs (labor costs, disposable briefs, and home care) and diagnostic costs. Indirect costs were defined as lost productivity. Table 2 summarizes both community and institutional costs. The total economic costs of OAB in the year 2000 were $13.5 billion. Of note is that the authors stated that institutional costs were conservative, based only on OAB patients with urge incontinence. Also, the costs of OAB increased with age, and women incurred a consistently higher cost than men. The authors concluded that the economic costs of OAB were comparable to such diseases as osteoporosis ($13.8 billion/year), VOL. 5 NO. 1 2003 REVIEWS IN UROLOGY 23 WHO 2nd International Consultation on Incontinence continued Table 2 Cost of Overactive Bladder (in Billions of Dollars) in the United States, 2000 Level Total Cost Community $9.1 Direct $8.3 Indirect $0.8 Institutional $4.4 gynecological/breast cancer ($11.1 billion/year), and Parkinson’s disease ($5.6 billion/year). The use of a clinically validated prevalence estimate to measure the cost-of-illness of OAB will aid in conducting future economic evaluations of various OAB treatments. Conservative Treatment for Overactive Bladder The new and improved anticholinergic drugs for OAB, tolterodine and oxybutynin controlled release, have been shown to have excellent efficacy and tolerability.7 Yet combining these agents with such conservative therapies as behavioral therapy or biofeedback might improve the treatment of OAB. Anders Mattiasson8 from Sweden presented the results of a multicenter, single-blinded study comparing the efficacy of tolterodine (2 mg p.o. q.d. for 24 weeks) in OAB patients, with or without bladder training. A total of 501 patients were randomized to receive either tolterodine alone (257) or tolterodine in com- bination with bladder training (244 patients). The bladder training was simple, consisting of a single-page instructional guide and voiding diaries. At each assessment (2, 12, and 24 weeks), patients in both groups showed significant improvements over baseline in the mean number of voids per 24 hours and in the volume of each void. However, after 12 weeks, the mean number of voids per 24 hours had decreased from baseline by 34% in those treated with differences remained significant after 2 and 24 weeks of treatment. No significant differences were noted in the improved perception of bladder treatment or in the decreased number of incontinent episodes. Both treatments were well tolerated, and only 15% of patients withdrew due to adverse events. The study concluded that bladder training augmented the effectiveness of anticholinergic drugs for the treatment of OAB. Anticholinergic Treatment of Incontinence in Nursing Home Residents Estimates show that at least 50% of nursing home residents are incontinent of urine.9 Griebling and associates10 from Kansas studied response to anticholinergic therapy in nursing home residents. Of the 96,267 patients screened, 843 met the inclusion criteria of age 65 years or older, incontinent of urine at initial assessment, new treatment with an anticholinergic After 12 weeks, the mean number of voids per 24 hours had decreased from baseline by 34% in those treated with tolterodine and bladder training, versus 24% in those treated with tolterodine alone. tolterodine and bladder training versus 24% in those treated with tolterodine alone (P < .0001). Also, after 12 weeks, the volume of each void had increased by 32% in those treated with tolterodine and bladder training, versus 23% in those treated with tolterodine alone (P < .01). These (oxybutynin or tolterodine) after initial assessment, and a minimum of 2 subsequent evaluations. Response to therapy was based on improvement in continence status. These 843 patients were also evaluated for continuance of medication. Incontinence improved in only Main Points • Primary care providers may find the Bladder Health Questionnaire to be an effective aid in referring incontinent patients for treatment. • Overactive bladder is common and costly: 16% of the U.S. population suffers from overactive bladder, at a cost of $13.5 billion a year. • Conservative treatments, such as behavioral modification, may augment the effectiveness of the newer anticholinergics in the treatment of overactive bladder. • Anticholinergic drugs may be less effective in the nursing home elderly patients. 24 VOL. 5 NO. 1 2003 REVIEWS IN UROLOGY WHO 2nd International Consultation on Incontinence 148 patients (17.6%) after anticholinergic initiation. Of the 695 patients who showed either no response or worsening of their incontinence, 73% remained on anticholinergics for no documented reason. This study underscores the magnitude of incontinence in the nursing homes. Response to anticholinergic drug appears to be lower than in the general public, but why this is so has not been fully elucidated. Perhaps the augmentation of drug therapy with behavioral therapy and time voiding, as described in the presentation from Sweden, would also be important in the nursing home setting. the treatment of urinary incontinence, an embarrassing and socially isolating disease. Unfortunately, since the consultation first met in 1998, incontinence still remains a stigma. Moreover, incontinence remains an increasing problem in both developed and Third World countries. This meeting in Paris presented a careful and critical review of the state of care for the treatment of urinary incontinence. Hopefully, the WHO can successfully convince world governments to allocate more attention and resources for this common and awful disease. 4. 5. 6. 7. 8. 9. References Conclusion 1. At the Second WHO Consultation on Incontinence, a group of worldwide experts from different specialties met to seek help and advice from those with an interest and commitment in 2. 3. Voelker R. International group seeks to dispel incontinence “taboo." JAMA. 1998;280:951–953. Abrams P, Khoury S, Wein A. W.H.O. 1st International Consultation in Incontinence. Plymouth, UK: Plymouth Distributors Ltd; 1999. Payne C, Stewart W, Wein A, et al. The Bladder Health Questionnaire (BHQ): the first clinically validated screening tool for bladder health problems. Presented at the World Health 10. Organization 2nd International Consultation on Incontinence; July 1–4, 2001; Paris, France. Nitti V. The prevalence of urinary incontinence. Rev Urol. 2001;3(suppl 1):S2–S6. Stewart W, Herzog A, Wein A, et al. Prevalence of overactive bladder in the United States: results from the NOBLE Program. Presented at the World Health Organization 2nd International Consultation on Incontinence; July 1–4, 2001; Paris, France. Hu T, Wagner T, Bentkover J, et al. Economic costs of overactive bladder. Presented at the World Health Organization 2nd International Consultation on Incontinence; July 1–4, 2001; Paris, France. Dmochowski R, Appell R. Advancements in pharmacologic management of the overactive bladder. Urology. 2000;56(suppl 6A):41–49. Mattiasson A. Effect of simplified bladder training and tolterodine treatment in overactive bladder patients. Presented at the World Health Organization 2nd International Consultation on Incontinence; July 1–4, 2001; Paris, France. Brandeis G, Baumann M, Hossain M, et al. The prevalence of potentially remediable urinary incontinence in frail older people: a study using the Minimum Data Set. J Am Geriatr Soc. 1997;45:179–184. Griebling T, Cuezze J, Redford L, et al. Anticholinergic medications in the treatment of urinary incontinence in nursing home residents: analysis using the Minimum Data Set (MDS). Presented at the World Health Organization 2nd International Consultation on Incontinence; July 1–4, 2001; Paris, France. VOL. 5 NO. 1 2003 REVIEWS IN UROLOGY 25